Para Philia

Paraphilic Disorders
By: Tesfaye S.Bsc,MSC,ICCMH)
05/11/2024 Minor Psychiatry Disorder 1

Paraphilic Disorders
 Paraphilia or perversions are sexual stimuli or acts that are deviations
from normal sexual behaviors, but are necessary for some persons to
experience arousal and orgasm.
 According to DSM-5, the term Paraphilic disorder is reserved for those
cases in which a sexually deviant fantasy or impulse has been
expressed behaviorally.
 Individuals with paraphilic interests can experience sexual pleasure, but
they are inhibited from responding to stimuli that are normally
considered erotic.
 DSM-5 lists pedophilia, frotteurism, voyeurism, exhibitionism, sexual
sadism, sexual masochism, fetishism, and transvestism with explicit
diagnostic criteria because of their threat to others and/or because they
are relatively common paraphilias.
Epidemiology of Paraphilic Disorder
Among legally identified cases of paraphilic disorders,
pedophilia is most common.
Persons with exhibitionism who publicly display themselves to
young children are also commonly apprehended.
Sexual sadism usually comes to attention only in sensational
cases of rape, brutality, and lust murder.
Persons with fetishism rarely become entangled in the legal
system.
As usually defined, the paraphilias seem to be largely male
conditions.
Fetishism almost always occurs in men.
Etiology of Paraphilic Disorder
 Psychosocial Factors
 Biological Factors
Diagnosis and clinical features
 In DSM-5, the criteria for paraphilic disorder requires the
patient to have experienced intense and recurrent arousal from
their deviant fantasy for at least 6 months and to have acted on
the paraphilic impulse.
 The presence of a paraphilic fantasy, however, may still distress
a patient even if there has been no behavioral elaboration.
 The fantasy distressing the patient contains unusual sexual
material that is relatively fixed and shows only minor variations.
1. Exhibitionism
 Exhibitionism is the recurrent urge to expose the genitals
to a stranger or to an unsuspecting person.
 Sexual excitement occurs in anticipation of the exposure,
and orgasm is brought about by masturbation during or
after the event.
 In almost 100 percent of cases, those with exhibitionism
are men exposing themselves to women.
 The dynamic of men with exhibitionism is to assert their
masculinity by showing their penises and by watching the
victims’ reactions—fright, surprise, and disgust.
DSM-5 Diagnostic criteria for Exhibitionism
A. Over a period of at least 6 months recurrent, intense
sexually arousing fantasies, sexual urges or behaviors
involving the exposure of one’s genitals to an
unsuspecting stranger.
B. The person has acted on these sexual urges or fantasies
cause marked distress or interpersonal difficult.
 Specifiers added to exhibitionistic disorder by DSM-5
differentiate arousal from exposing genitals to prepubertal
children, to physically mature individuals, or to both
prepubertal children and physically mature individuals.

2. Voyeurism
Voyeurism, also known as scopophilia, is the recurrent
preoccupation with fantasies and acts that involve
observing unsuspecting persons who are naked or engaged
in grooming or sexual activity.
Masturbation to orgasm usually accompanies or follows
the event.
The first voyeuristic act usually occurs during childhood,
and the paraphilia is most common in men.
When persons with voyeurism are apprehended, the
charge is usually loitering.
3. Fetishism
 In fetishism the sexual focus is on objects (e.g., shoes, gloves,
pantyhose, and stockings) that are intimately associated with the
human body, or on non genital body parts.
 The latter focus is sometimes called partialism.
 Partialism is concentrate their sexual activity on one part of the
body to the exclusion of all others.
 The particular fetish used is linked to someone closely involved
with a patient during childhood and has a quality associated with
this loved, needed, or even traumatizing person.
 Usually, the disorder begins by adolescence, although the fetish may
have been established in childhood.
 Once established, the disorder tends to be chronic.
3. Fetishism cont…
 Sexual activity may be directed toward the fetish itself
(e.g., masturbation with or into a shoe), or the fetish may
be incorporated into sexual intercourse (e.g., the demand
that high-heeled shoes be worn).
 The disorder is almost exclusively found in men.
 According to Freud, the fetish serves as a symbol of the
phallus to persons with unconscious castration fears.
 Learning theorists believe that the object was associated
with sexual stimulation at an early age.

DSM-5 Diagnostic criteria for Fetishism
involving the use non objects (e.g. female undergarments)
B. The fantasies , sexual urges, or behaviors cause clinically
significant distress or impairment in social, occupational,
other important areas of functioning.
C. The fetish objects are not limited to articles of female
clothing used in cross dressing (as in transvestic
fetishism) or devices designed for the purpose of tactile
genital stimulation ( e.g. a vibrators).

4.Frotteurism
 Frotteurism is usually characterized by a man’s rubbing his
penis against the buttocks or other body parts of a fully clothed
woman to achieve orgasm.
 At other times, he may use his hands to rub an unsuspecting
victim.
 The acts usually occur in crowded places, particularly in
subways and buses.
 Those with frotteurism are extremely passive and isolated, and
frottage is often their only source of sexual gratification.
 The expression of aggression in this paraphilia is readily
apparent.
DSM-5 Diagnostic criteria for Frotteurism
involving touching and rubbing against a unconsenting
person.
B. The person has acted on these sexual urges or fantasies
cause marked distress or interpersonal difficult.

5. Pedophilia
 Pedophilia involves recurrent intense sexual urges toward, or
arousal by, children 13 years of age or younger, over a period
of at least 6 months.
 Persons with pedophilia are at least 16 years of age and at least
5 years older than the victims.
 When a perpetrator is a late adolescent involved in an ongoing
sexual relationship with a 12- or 13-year-old, the diagnosis is
not warranted.
 Most child molestations involve genital fondling or oral sex.
 Vaginal or anal penetration of children occurs infrequently,
except in cases of incest.
Pedophilia cont…
 DSM-5 adds the following specifiers to a diagnosis of
pedophilic disorder: sexually attracted to males; sexually
attracted to females; or sexually attracted to both.
 Of persons with pedophilia, 95 percent are heterosexual,
and 50 percent have consumed alcohol to excess at the
time of the incident.
 In addition to their pedophilia, a significant number of the
perpetrators are concomitantly or have previously been
involved in exhibitionism, voyeurism, or rape.

6. Sexual Masochism
According to the DSM-5, persons with sexual masochism have a
recurrent preoccupation with sexual urges and fantasies
involving the act of being humiliated, beaten, bound, or
otherwise made to suffer.
A specifier added to this disorder diagnosis is: with
asphyxiophilia; also called autoerotic asphyxiation, this is the
practice of achieving or heightening sexual arousal with
restriction of breathing.
Sexual masochistic practices are more common among men than
among women.
About 30 percent of those with sexual masochism also have
sadistic fantasies.
7. Sexual Sadism
 DSM-5 defines sexual sadism as the recurrent and intense sexual
arousal from the physical and psychological suffering of another
person.
 A person must have experienced these feelings for at least 6
months, and must have acted on sadistic fantasies to receive a
diagnosis of sexual sadism disorder.
 The onset of the disorder is usually before the age of 18 years,
and most persons with sexual sadism are male.
 John Money lists five contributory causes of sexual sadism:
hereditary predisposition, hormonal malfunctioning, pathological
relationships, a history of sexual abuse, and the presence of other
mental disorders.
8. Transvestism
 Transvestism, formerly called transvestic fetishism, is described
as fantasies and sexual urges to dress in opposite gender clothing
as a means of arousal and as an adjunct to masturbation or coitus.
 The diagnosis is given when the transvestic fantasies have been
acted upon for at least 6 months.
 DSM-5 requires specifiers with a diagnosis of transvestic
disorder:
 with fetishism is added if the patient is aroused by fabrics,
materials, or garments;
 with autogynephilia is added if the patient is sexually aroused
by thoughts or images of himself as a female.

Other Specified Paraphilic Disorder
Telephone and computer scatologia.
Necrophilia.
Partialism.
Zoophilia.
Masturbation
Hypoxyphilia

COURSE AND PROGNOSIS
The difficulty in controlling or curing paraphilic disorders
rests in the fact that it is hard for people to give up sexual
pleasure with no assurance that new routes to sexual
gratification will be secured.
A poor prognosis for paraphilic disorder is associated with
an early age of onset, a high frequency of acts, no guilt or
shame about the act, and substance abuse.
The course and the prognosis are better when patients have
a history of coitus in addition to the paraphilia, and when
they are self-referred rather than referred by a legal agency.

TREATMENT
 Five types of psychiatric interventions are used to treat
persons with paraphilic disorder and paraphilic interests:
 External control, reduction of sexual drives, treatment of
comorbid conditions (e.g., depression or anxiety),
cognitive-behavioral therapy, and dynamic psychotherapy.
 Prison is an external control mechanism for sexual crimes
that usually does not contain a treatment element.
 Ant androgens, such as cyproterone acetate and
medroxyprogesterone acetate (Depo-Provera) in the may
reduce the drive to behave sexually by decreasing serum
testosterone levels to subnormal concentrations.
Treatment cont…
 Serotonergic agents, such as fluoxetine (Prozac), have been used
with limited success in some patients with paraphilia.
 Cognitive-behavioral therapy is used to disrupt learned paraphilic
patterns and modify behavior to make it socially acceptable.
 The interventions include social skills training, sex education,
cognitive restructuring (confronting and destroying the
rationalizations used to support victimization of others), and
development of victim empathy.
 Insight-oriented psychotherapy is a long-standing treatment
approach.
 Patients have the opportunity to understand their dynamics and the
events that caused the paraphilia to develop.
Gender Dysphoria
 Refer to those persons with a marked incongruence
between their experienced or expressed gender and the one
they were assigned at birth.
 Persons with gender dysphoria express their discontent with
their assigned sex as a desire to have the body of the other
sex or to be regarded socially as a person of the other sex.
 Individuals with gender dysphoria have a marked
incongruence between the gender they have been assigned
to (usually at birth, referred to as natal gender) and their
experienced/ expressed gender.

ETIOLOGY
Biological Factors
Psychosocial Factors

DSM-5 Diagnostic Criteria for Gender Dysphoria
Gender Dysphoria in Children
A. A marked incongruence between one’s experienced/expressed
gender and assigned gender, of at least 6 months’ duration, as
manifested by at least six of the following (one of which must be
Criterion A1):
1. A strong desire to be of the other gender or an insistence that
one is the other gender (or some alternative gender different from
one’s assigned gender).
2. In boys (assigned gender), a strong preference for cross-
dressing or simulating female attire: or in girls (assigned gender),
a strong preference for wearing only typical masculine clothing
and a strong resistance to the wearing of typical feminine
clothing.

DSM-5 Diagnostic Criteria for Gender Dysphoria cont…
3. A strong preference for cross-gender roles in make-believe play or
fantasy play.
4. A strong preference for the toys, games, or activities stereotypically
used or engaged in by the other gender.
5. A strong preference for playmates of the other gender.
6. In boys (assigned gender), a strong rejection of typically masculine
toys, games, and activities and a strong avoidance of rough-and-
tumble play; or in girls (assigned gender), a strong rejection of
typically feminine toys, games, and activities.
7. A strong dislike of one’s sexual anatomy.
8. A strong desire for the primary and/or secondary sex characteristics
that match one’s experienced gender.
B. The condition is associated with clinically significant distress or
impairment in social, school, or other important areas of functioning.
Gender Dysphoria in Adolescents and Adults
A. A marked incongruence between one’s
experienced/expressed gender and assigned
gender, of at least 6 months’ duration, as manifested by at
least two of the following:
1. A marked incongruence between one’s
experienced/expressed gender and primary
and/or secondary sex characteristics (or in young
adolescents, the anticipated secondary sex characteristics).
2. A strong desire to be rid of one’s primary and/or secondary sex
characteristics because of a marked incongruence with one’s
experienced/expressed gender (or in young adolescents, a desire to
prevent the development of the anticipated secondary
sex characteristics).
3. A strong desire for the primary and/or secondary sex
characteristics of the other gender.
4. A strong desire to be of the other gender (or some
alternative gender different from one’s assigned gender).
5. A strong desire to be treated as the other gender (or some
alternative gender different from one’s assigned gender).
6. A strong conviction that one has the typical feelings and
reactions of the other gender (or some alternative gender
different from one’s assigned gender).
B. The condition is associated with clinically significant
distress or impairment in social, occupational or other
important areas of functioning.
COURSE AND PROGNOSIS
Children
 Children typically begin to develop a sense of their gender
identity around age 3.
Gender dysphoria cont…
 At this point they may develop gendered behaviors and
interests, and some may begin to express a desire to be
another gender.
 Children diagnosed with gender dysphoria do not
necessarily grow up to identify as transgender adults.
 Children diagnosed with gender dysphoria show higher
rates than other children of depressive disorders, anxiety
disorders, and impulse-control disorders.
 There are also reports that those diagnosed with gender
dysphoria are more likely than others to fall on the autism
spectrum.
Gender dysphoria cont…
Adults
 Some people diagnosed with gender dysphoria as adults recall the
continuous development of transgender identity since childhood.
 In these cases, some have periods of hiding their gender identity,
many entering into stereotypic activities and employment in order
to convince themselves and others that they do not have gender
nonconforming identities.
 Others do not recall gender identity issues during childhood.
 Adults diagnosed with gender dysphoria show higher rates than
other adults of depressive disorders, anxiety disorders, suicidality
and self-harming behaviors, and substance abuse.

TREATMENT
 Treatment of gender identity issues in children typically consists
of individual, family, and group therapy that guides children in
exploring their gendered interests and identities.
 In addition to providing psychotherapy, many clinicians use
these adolescents’ reactions to the first signs of puberty as a
compass to determine if puberty blocking medications should be
a consideration.
 Puberty-blocking medications are gonadotropin-releasing
hormone (GnRH) agonists that can be used to temporarily block
the release of hormones that lead to secondary sex
characteristics, giving adolescents and their families time to
reflect on the best options moving forward.
Treatment cont…
 Hormone treatment of transgender men is primarily accomplished
with testosterone, usually taken by injection every week or every
other week.
 Transgender women may take estrogen, testosterone-blockers, or
progesterone, often in combination.
 Many fewer people undergo gender-related surgeries than take
hormones.
 The most common type of surgery for both trans-men and trans-
women is “top surgery,” or chest surgery.
 Transgender men may have surgery to construct a male contoured
chest.
 Trans-women may have breast augmentation.
The end of Second Part
Make people Free from Paraphilic and Related Disorders!
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ATTENTION!!!

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Paraphilic Disorders

By: Tesfaye S.Bsc,MSC,ICCMH)

05/11/2024 Minor Psychiatry Disorder 1

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THANK FOR YOUR

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